ADULTS IN MOTION APPLICATION FORM ~ A.I.M Hamilton
In addition to this application form the participant and a caregiver will be required to meet with an A.I.M. staff to assess that the needs of the individual can be properly met by the program.
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Participant Information
Participant's Full Name *
Participant Nickname
(The name they prefer to be called by)
Date of Birth *
MM
/
DD
/
YYYY
Address *
City *
Postal Code *
Transportation & Attendance Information
Which Program(s) is Your Participant Interested in? *
Required
How Will the Participant Arrive and Depart From the Program? (Family, Mobility Bus, Taxi, Independently...) PLEASE ALSO INCLUDE A LIST OF ALL PERSONS APPROVED TO PICK UP PARTICIPANT. *
Which Days Would You Like to Attend the AIM Program? *
Required
Medical Information
Health Card Number w/Version Code *
Family Doctor's Name *
Family Doctor's Phone Number *
Diagnosis Info *
Does the Participant Have Any Previous or Current Aggressive, Outbursts, or Running-Away Behaviours? *
Behavioural Triggers and Calming Strategies *
IF NOT100% independent in the washroom, please list ANY specific requirements for assistance in the washroom, including any material needs (such as: what level of assistance is needed, monitoring use of paper, assistance with feminine hygiene products, etc.) *
Medications & Medical Needs
Allergies *
Special Dietary Needs
Please List All Previous Significant Injuries (breaks, sprains, twists, etc) *
Is the Sensory Room Safe for Participant? *
The AIM Sensory Room has black light/moving light technology. Strobe lights are NOT in the sensory room.
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